INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 3, 2013 through January 4, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Harwood House was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
The following deficiencies were identified during this inspection.
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Plan of Correction
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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of personnel records and administrative documentation, the facility failed to document close supervision in two of two personnel records reviewed.
The findings include:
On January 3, 2013, the personnel and training records of two counselor assistants were reviewed for documentation of close supervision. The facility failed to document close supervision in two of two records reviewed, specifically for employees # 5 and 6.
Employee # 5 was hired as a counselor assistant on 5/15/12. Employee # 5 had an Associate's Degree in Social/Behavioral Science and was required to receive close supervision for at least the first 9 months of employment because there was less than two years of clinical experience. The facility did not document close supervision for employee # 5.
Employee # 6 was hired as a counselor assistant on 2/16/12. Employee # 6 had a Bachelor's Degree in Psychology and was required to receive close supervision for at least the first 6 months of employment because there was less than one year of clinical experience. The facility did not document close supervision for employee # 6.
The Project Director confirmed the findings.
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Plan of Correction
It is the responsibility of the clinical supervisor completing the supervision to supervise and document notes consistant with requirements for close supervision of counselor assistant.
The clinical supervisor will be trained by the director of the program on requirments of direct observation and close supervision of counselor assistants on 1/21/13 during her supervision meeting by reviewing licensing alert 4-02.
Employee #5 and 6 are now counselors and will attend weekly group supervision and monthly individual supervision with the clinical supervisor.
It is the responsibility of the clinical supervisor to ensure that all counselor assistant supervision is scheduled and documented according to supervision regulations.
It is the responsibility of the program director to ensure overall compliance. |
709.22(e)(3) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(3) A statement disclosing the names of officers, directors and principal shareholders, where applicable.
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Observations
Based on a review of the 2011 - 2012 annual report, the governing body failed to make available to the public an annual report which included a statement disclosing the names of officers, directors and principal shareholders.
The findings include:
The 2011 - 2012 annual report was reviewed on January 3, 2013. There was no documentation of a statement disclosing the names of officers, directors and principal shareholders.
The Project Director confirmed the findings.
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Plan of Correction
it is the responsibility of the Executive Director to ensure that the names of the Board of Directors are listed in the Annual Report.
The Executive Director added the names of the Board of Directors to the annual report on 1/4/2013 and presented the updated report to the Board members during the monthly board meeting on 1/14/2013.
The Executive Director is responsible for including the Board of Director names on the annual reports when written.
It is the responsibility of the Board of Directors to ensure overall compliance. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on a physical plant inspection and observation, the facility failed to maintain confidentiality of client identity.
The findings include:
On January, 3, 2013, female residents as well as the entire female lounge could be visibly seen from outside of the facility. The female lounge has a large window that is ground level.
It was observed at approximately 8:30 AM, 1:00 PM, and 4:00 PM that the window blinds on the female unit were pulled all the way up and allowed for a passerby on the street to clearly see who and what was in the facility. In addition, the female residents could clearly see out of the window.
The facility failed to ensure privacy and maintain the confidentiality of client identity.
The Project Director confirmed the findings.
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Plan of Correction
It is the responsibility of the staff on duty to uphold procedure on Confidentiality of client identity.
All staff will be trained on 1/21/13 on Confidentiality of client identity at weekly staff meeting and at the monthly residential program worker meeting. Procedure of monitoring that blinds are down in lounge of female unit)
The supervisor of residential program workers and clinical supervisor will be responsible for maintaining client identity confidentiality.
The Executive Director is responsible to ensure overall compliance. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document type and frequency of treatment and rehabilitation services on the individual treatment plan in six of six records reviewed.
The findings include:
On January 4, 2012, seven individual treatment plans were reviewed for documentation of type and frequency. The facility failed to document the type and frequency of treatment and rehabilitation services in six of six records reviewed, client records # 1, 2, 3, 4, 5, and 7.
The Project Director and clinical supervisor confirmed the findings.
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Plan of Correction
It is the responsibility of the counselor completing the individual treatment plan to document on the plan type and frequency of treatment and rehabilitation services.
The clinical team was trained by the Executive Director on 1/7/2013 during the Monday staff meeting on inclusion of weekly individual sessions and weekly small group meeting on all individual treatment plans.
It is the responsibility of the clinical supervisor to ensure that type and frequency are included on all individual treatment plans during review and signing of plan.
It is the responsibility of the Executive Director to ensure overall compliance.
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709.53(a)(12) LICENSURE Work as treatment
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to verify that any work done by the client is an integral part of the treatment and rehabilitation plan.
The findings include:
On January 4, 2012, seven client records requiring documentation of work therapy as an integral part of treatment were reviewed. The facility failed to document work therapy on the individual treatment plan or treatment plan updates in six of seven records reviewed, client records # 1, 3, 4, 5, 6 and 7.
An interview with the Project Director confirmed that clients participate in work outside of cleaning their personal space and that work as therapy was not documented on the treatment plans.
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Plan of Correction
It is the responsibility of the counselor completing the individual treatment plan to document on the plan work therapy and to document on the treatment plan updates work therapy.
The clinical team was trained on 1/7/2013 during their weekly staff meeting on inclusion of work therapy on all individual treatment plans and treatment plan updates.
It is the responsibility of the clinical supervisor to ensure that work therapy is included on treatment plans and updates to be checked during review and signing of plans.
It is the responsibility of the Executive Director for overall compliance. |